KTS Pooled Trust Medicaid Forms Download Page

In order for a Trust to be submitted to Medicaid the following is also necessary:

  1. LDSS 486T (Medical Report for Determination of Disability) to be completed and signed by doctor.

  2. Recent Progress Notes from doctor’s office (notes the doctor took during the recent visits).

  3. LDSS 1151 (Disability Questionnaire) to be filled out by the applicant or someone familiar with them.

  4. A completed HIPAA Form (OCA 960) initialed in section 9(b) and signed by the person joining the Trust.

  5. A Sample HIPAA is also included for reference.